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Academic Year ContractThis is my personal contract with the University of Toledo Upward Bound Program throughgraduation from the program. I hereby agree to participate and represent the program under thefollowing guidelines.1.2.3.4.5.6.7.I will attend Classroom Instruction (CI).I will attend Saturday Enrichment Academy (SEA).I will not miss more than two (2) days of school per nine (9) weeks, unless ill.I will enroll in college preparatory classes.I will enroll in college courses while in high school when eligible to do so.My goal is to maintain no less than a 2.5 or above GPA in all of my academic classes.Should my GPA fall below a 2.5, in addition to CI and SEA, I will attend tutorials twiceweekly.8. In the event that I maintain a 2.5 GPA, but earn a grade of D or below in any subject, Iwill, in addition to CI and SEA, attend tutorials.9. I will be responsible for informing my instructors and Upward Bound staff when havingproblems in any of my academic classes.10. I will complete and submit all assignments and program forms necessary for thedevelopment and execution of my curriculum plan.11. I understand that Upward Bound is a college preparatory program and state that upongraduation from high school it is my sincere intention to go on to post-secondaryeducation (college) to pursue an associate’s or bachelor’s degree.12. I understand Upward Bound is a full-year, four year program and I will make every effortto regularly participate.13. Areas where I need strengthening, instruction and tutorial help are:a.b.c.The above agreement will be considered as a binding contract. [Upward Bound staff expects youto fulfill your commitment.] Attitude, conduct and performance will be evaluated each nine (9)weeks to determine how serious students are in their preparation for post-secondary education.Students who are not committed to Upward Bound or are unable to complete the specifiedrequirements should strongly evaluate whether or not post-secondary education is important orattainable for them. If not, we strongly suggest other alternatives.Student SignatureUpward Bound DirectorParent Signature

Confidential Financial Information(Fill out and sign this page regardless of income amount or source)DateStudent’s Name1. Taxable income for the year (1040 line 43, 1040A line 27) . Submit SIGNED copy of 1040/1040A only, do not submit any schedules or attachments.2. Number of Dependents claimed . .Number of family members supported by this income . 3. If your family was not large enough to require that youfile an income tax return, please indicate the approximateamount of your family income . The number of family members supported by this income . . .4. Does your family live in federally subsidized housing . . 5. Are any members of your family on state/federal welfare/social security/unemployment compensation programs? . If yes, you must submit a letter of your benefits.6. In order for your son/daughter to qualify for Upward Bound, you must be able to show that youcould not afford to pay for such services yourself. Usually, this decision is based on your lastyear’s income, but in special cases, it can be based on this year’s income. If you can show therehas been a major change in your family’s financial condition since last year, (i.e., one or morefamily members being out of work) explain your situation in the following space or attach a letterof explanation.Signature of Parent/Guardian(s)

DECLARATION OF FIRST-GENERATION STATUS*Date:I/We, and(Name, Please Print), am/are the custodial parent(s) of(Name, Please Print). Further, I declare that:(Name, Please Print) I and/or my spouse HAVE as of the date of this application abachelor’s degree. I and/or my spouse DOES NOT HAVE as of the date of thisapplication a bachelor’s degree.Parent Signature: Date: / , 20 *Answer form on the status of the custodial parent(s) with whom the student/applicant actually resides.

Release of High School/College InformationExpected High School Grad Year20 Privacy Act: In accordance with the Privacy Act of 1974 (Public Law No. 93-579, 5 U. S.C. 552A), you are herebynotified that the Department of Education is authorized to collect information to implement the Upward Boundprogram under Title IV of the Higher Education Act of 1965, as amended (Pub. Law 102-325, sec. 402C). Inaccordance with this authority, the Department receives and maintains personal information on participants in theUpward Bound program. The principle purpose for collecting this information is to administer the program, includingtracking and evaluating participants’ academic progress. The information that is collected on this form will be retainedin the program files and may be released to other Department officials in the performance of official duties.TO THE UNIVERSITY OF TOLEDO UPWARD BOUND PROGRAM:I/We (circle one) and do herebyauthorize you to release information including the comprehensive and cumulative school records ofmy/our child, (student’s name) school identification number, such as grades, class, rank, school attendance, school activities, teacherevaluations, standardized test scores, academic performance and official transcripts, to bona fiderepresentatives of the University of Toledo Upward Bound Program for Upward Bound datacollection/ follow-up and general informational purposes. This information can be released whetheror not the student mentioned above is in regular enrollment or when the student has transferred to anew location.I/We, certify that I/We am/are the parent(s), custodial parent(s), or guardian(s) of(student’s name) and that I/We signed this release form of theUniversity of Toledo Upward Bound Program on the day of , 20 .I, , the student. understand that The University of Toledo UpwardBound Program is a grant funded program by the US Department of Education that is required totrack student college enrollment progress SIX YEARS AFTER high school graduation; thus, thisRelease of Information will be in effect up to six years after high school graduation.Applicant/Student SignatureDateParent/Guardian SignatureDateParent/Guardian (optional)Date

Permission and Release ConsentMy/Our, son/daughter, , (student’s name) has my/ourpermission to participate in the University of Toledo Upward Bound Program for the summer (JuneJuly) and the Academic components (September-May).Permission for Field TripsI/We give permission for (student’s name) to participate in field tripsfor educational benefits of the University campus as planned and supervised by members of theUpward Bound staff. I/We understand that the Program will ordinarily provide transportation for trips,but in some cases, the student may be asked to provide his/her own transportation.Release from LiabilityI/We release the University of Toledo and its employees from any liabilities for accidents or normalhealth difficulties which may occur during the course of the field trips and program activities. I/Wewill notify the Program Director in writing of any medical or dental problems my/our child has had thatwill limit his/her activities.Release S# consent to the release of any and all information regarding the health andphysical conditions of my/our child to a bona fide representative of the University of Toledo UpwardBound Program.Picture ReleaseI/We give permission for (student’s name) picture to be taken inconnection with the activities of the Project: Upward Bound at the University of Toledo, and itsagencies to be used in newspapers, television, magazine articles and talk concerning the project.Program Research ConsentI/We give permission and consent of my minor child to participate in any Upward Bound Programand/or TRiO Program research involving surveys, questionnaires etc. I am aware that participation isvoluntary and will have no detrimental effect on my child’s participation and relationship with UpwardBound and TRiO Programs. Also, I am aware that my child’s name will never be used or associatedwith any project research.Parent ParticipationI/We understand that in order for my/our son/daughter to participate, I/We may be asked to participatein Upward Bound activities during the year.Parent VisitationsI/We understand that I/We am/are welcome at all times to visit the campus, inspect facilities, observeactivities, and confer with the Program Director, Faculty, and staff.Parent/Guardian(s) SignatureDateParent/Guardian(s) SignatureDateStudent SignatureDate

Visitation and Travel ConsentHold Harmless AgreementThe University of Toledo Upward Bound Program offers a unique opportunity to participate in fieldexperiences for educational purposes. The program relies on the cooperation and goodwill for variousprivate businesses, individuals, organizations, and government entities. Because of our obligation tothose persons and agencies, and because we understandably cannot assume responsibility for thevarious persons and agencies, which are in different ways connected with our program, we ask that youadhere to the following terms and conditions of participation. Your dated signature indicates that youunderstand and agree to the terms and conditions.Agreement and ReleaseWhereasI/We,,parent(s)/guardianof, (student’s name) a student registered for and desiring toparticipate inactivities associated with the Upward Bound Program; andWhereas I/We parent/guardian(s) of , do hereby provideauthorization for my/our child to travel on all Upward Bound sponsored trips and affairs in vehiclesand other modes of transportation supplied by the Upward BoundProgram for the entire period inwhich my/our child is enrolled in the University ofToledo Upward Bound Program. Thisauthorization covers absences from school whichwill be deemed excused since these activities areeducationally sound. I/We understand that the Upward Bound Program will not be held responsiblewhen my/our child chooses to ride in cars or other modes of transportation NOT officially providedby the Upward Bound Program; andWhereas I/We further understand that the student is subject to the behavioral directions of theleaders of this trip and that the consumption of alcohol and use of cigarettes and/or drugs is strictlyprohibited. Behavior detrimental to the activity, as determined by the trip leaders, will result indismissal from the Upward Bound Program.I/We further understand that the Upward Bound Program will, in most cases,covertransportation and lodging for each student. I/We, parent(s) or guardian(s) of said student, will beresponsible for covering his/her expenses including food costs when appropriate. The University ofToledo is not liable for injuries, theft, etc., during thetrips.Now therefore, I/We agree to hold the Upward Bound Program staff, drivers of vehicles;supervisors of this program; the University of Toledo; its Board of Trustees; officers and employeesharmless for any direct, indirect, special or consequentialdamages which I/We may incur or beheld liable for as a result of’s (student’s name) participation in theactivities. I/We have readthe above terms of this agreement and understand and agree to the termsand conditions.This Agreement/Release shall be binding upon heirs, administrators, executorsand assigns, of the undersigned.Name (print)Address City/State/ZipParent/Guardian(s) Signature Date

Emergency, Insurance, and Medical Care InformationTO BE COMPLETED BY PARENT/GUARDIAN:STUDENT NAME: D.O.B SS#In case of an emergency, parent(s)/guardian(s) or the two alternate persons listed below should becontacted:Parent(s)/Guardian(s) NameAddressStateCityZipDay Phone ( )Evening Phone ( )Alternate 1 NameAddress City State ZipDay Phone ( )Evening Phone ( )Alternate 2 NameAddress City State ZipDay Phone ( )Evening Phone ( )SPECIAL CARE REQUIREDListed below is special personal, medical, or dental care required for my child that will limit his/heractivities. Matters of a confidential nature may be communicated to the director in a separateletter.I GIVE THE UPWARD BOUND PROGRAM STAFF THE AUTHORITY TO DISPENSEFIRST AID CARE AND/ OR EMERGENCY MEDICAL CARE TO MY SON/ DAUGHTER ASDEEMED NECESSARY.Parent(s)/Guardian(s) Signature(s) DateParent(s)/Guardian(s) Insurance InformationHuman Services/ ADC case number:

Health Insurance InformationAs the health care provider for students at the University of Toledo, the Student Medical Centerwill offer on-Campus Summer programs, a means by which to provide medical/nursing care toprogram participants while they are on our campus. Providing accessible, customer-orientedservice to program participants is our primary goal.As part of this arrangement, we will provide participants with medical care while on campus asoutlined below:1. The Student Medical Center shall provide accessible, quality treatment and service for minorillnesses and injuries during our normal summer business hours.2. The Student Medical Center shall provide such services for a nominal fee. Upon agreement ofthis proposal, program participants will pay for any fees incurred. The fee for each office visitis 36 as of 4/30/03, however fees may increase. Additional fees are assessed for procedures,laboratory testing, medicine, and certain medical supplies.The Upward Bound program will supply the Student Medical Center with the Agreement forServices, Consent to Treat forms and billing information.Program Participants utilizing the Student Medical Center services will also be required to sign forthe receipt of a Notice of Privacy Practices brochure. This brochure describes how medicalinformation may be used and disclosed, and how to access the information.INSURANCE INFORAMTIONInsurance Carrier:Address:Policy # Group #Subscriber / Policyholder:Social Security # Relationship to PatientAddress:Place of Employment:Address:ACKNOWLEDGMENT: I hereby assign my insurance benefits to be paid directly to me not to TheUniversity of Toledo Upward Bound Program. I understand that I am responsible for all services e)Release: I authorize The University of Toledo Health Services to release any information to processany claim.Signature:(Parent)(Date)

Upward Bound is an academic program which provides fundamental support to low- income, firstgeneration or students with disabilities in their precollege performance to increase access to higher education. Upward Bound’s goal is to increase the rate at which participants complete high school and enroll inand graduate from any college with an associate’s or bachelor’s degree. Thus, we are looking for studentswho have academic potential but are unlikely to apply for admission to an institution of post-secondaryeducation for various reasons. By completing the following, you are helping us identify sound academicstudents eligible to participate in the program. Any information that we receive will be used for UpwardBound purposes only and will be kept confidential.Applicant’s Name:From your observation and interactionwith the applicant, would you say that he/she:YesNoHas the academic potential for post-secondary education?Would probably apply to a post-secondary institution without the assistance ofthe Upward Bound Program?Would probably be accepted by a post-secondary institution without the helpof the Upward Bound Program?Currently lacks motivation?Currently lacks goals and/or direction?Has an academic need for the program?Has a social need for the program?Has a personal need for the program?Demonstrates behavior which you believe is counter-productive to his/hereducational success?Would benefit from cultural enrichment activities which are available in theprogram?Is in need of tutoring and/or advising and/or other support services at thistime?Do you believe this student needs the additional academic services UpwardBound has to offer?Do you recommend this student for participation in TheUniversity of Toledo Upward Bound Program?Your Name Printed TitleSignature SchoolPlease include any additional comment you believe would be helpful in evaluating students’ academic needto participate in Upward Bound on the reverse side of this form.

Upward Bound is an academic program which provides fundamental support to low- income, firstgeneration or students with disabilities in their precollege performance to increase access to higher education. Upward Bound’s goal is to increase the rate at which participants complete high school and enroll inand graduate from any college with an associate’s or bachelor’s degree. Thus, we are looking for studentswho have academic potential but are unlikely to apply for admission to an institution of post-secondaryeducation for various reasons. By completing the following, you are helping us identify sound academicstudents eligible to participate in the program. Any information that we receive will be u

Upward Bound Program University of Toledo Student Union, Room 1512 2801 W. Bancroft St. Toledo, OH 43606 Upon receipt of the completed application and copies of the verification documentation, your student will be scheduled for an interview with the Upward Bound Program. I